Pelvic floor dysfunction is a lot more common than you think. In fact, 1 in 3 Canadian women are affected by a condition associated with pelvic floor dysfunction. Pelvic dysfunction isn’t just a “women’s disorder” though; men and children can have pelvic floor dysfunction as well. This guide will help you better understand what the pelvic floor muscles do, the various conditions of pelvic dysfunction, and how pelvic physiotherapy can help.
- Pelvic Floor Muscles
- Pelvic Floor Dysfunction
i) Hypotonic Pelvic Floor Dysfunction
– Urinary Incontinence
– Pelvic Organ Prolapse
ii) Hypertonic Pelvic Floor Dysfunction
– Pudendal Neuralgia
– Chronic Prostatitis
- Pelvic Physiotherapy
i) What is Pelvic Physiotherapy?
ii) Pelvic Physiotherapy Treatments and Exercises
– Manual Therapy
– Exercise Programs
– Electrical Stimulation Devices
– Bladder Symptom Diary
iii) How to Find a Pelvic Physiotherapist
iv) Pelvic Physiotherapy Costs
- Do You Need Pelvic Physiotherapy?
Pelvic Floor Muscles
Pelvic floor muscles are the layer of muscles that support the pelvic organs, such as the bladder, bowel, and uterus. These muscles span to the bottom of the pelvis and provide support for the pelvic organs that lie in that area.
In addition to supporting your pelvic organs, the pelvic floor muscles have holes for passages. For men, the passages include the urethra and anus; for women, the passages include the urethra, vagina, and anus.
Part of the pelvic floor’s duty is to wrap firmly around these passageways to help keep them shut. By working alongside the muscles for the anus (the anal sphincter) and urethra (the urethral sphincter), the pelvic floor muscles help prevent the uncontrolled release of feces and urine.
The pelvic floor muscles are also important for a number of other reasons, including:
- Sexual function in both men and women.
- Support for the baby during a woman’s pregnancy and during the birthing process
- To work with the abdominal and back muscles to support and stabilise the spine
Pelvic Floor Dysfunction
Most people with pelvic floor dysfunction don’t seek proper care for themselves. To put it into perspective, 1 in 10 Canadians experience incontinence, yet only 26% of those experiencing incontinence have consulted a healthcare professional about their symptoms.
Most pelvic floor dysfunction conditions are a result of pelvic floor muscles either being too weak (hypotonicity) or too tight (hypertonicity). Pelvic floor muscles often become hypotonic or hypertonic because of the following reasons:
- Pregnancy and childbirth: Women that have had multiple births, instrumental births (use of forceps), or experience tearing from birthing a larger baby are at a greater risk of pelvic floor damage. To learn more, read Pelvic Pain During Pregnancy: What’s Causing It and How You Can Treat It.
- Chronic coughing: Individuals that suffer from severe and ongoing coughing – from conditions like asthma, bronchitis, or smoker’s cough – may have an increased risk of urinary incontinence and pelvic organ prolapse.
- Old age: Similar to the effects of ageing on joints and other muscles, the pelvic floor muscles become weaker as we get older.
- Obesity: Individuals that are overweight are at a higher risk of putting strain on the pelvic floor muscles, resulting in pelvic floor dysfunction.
- Straining on the toilet: This is often a result of constipation and can result in a rectal prolapse.
- Heavy lifting: When lifting something heavy, this can put pressure on the pelvic floor, resulting in pelvic organ prolapse. Individuals that work in nursing, delivery services, or gym training are at higher risk of pelvic floor dysfunction due to their need to lift heavy objects.
Hypotonic Pelvic Floor Dysfunction
Hypotonic pelvic floor muscles are muscles that are too weak. When a man or woman has weak pelvic floor muscles, it means that the muscles are not providing enough support for the bowels, bladder, and/or uterus.
There are two main conditions that are caused by weak pelvic floor muscles: urinary incontinence and pelvic organ prolapse (POP).
Urinary Incontinence is the involuntary loss of urine. Depending on the type and severity, some individuals can experience minor leaks while others lose small to moderate amounts of urine more frequently. If you suffer from urinary leakage, please know that it is very common – approximately 3.3 million Canadians suffer from incontinence. 
There are 5 different types of urinary incontinence:
- Stress Incontinence: Involuntary leakage occurs when an increased pressure is put on the intra-abdominal muscles from such activities as: coughing, sneezing, laughing, lifting, and exercise.
- Urge Incontinence: An overwhelming urge to urinate, but unable to make it to the bathroom in time.
- Overflow Incontinence: The bladder doesn’t empty normally (for example, dribbles) and becomes very full as a result.
- Functional Incontinence: Urinary leakage associated with health issues or environmental factors that prevent you from going to the washroom. These factors may include cognitive or physical concerns, psychological unwillingness, or physical barriers to the toilet.
- Mixed Incontinence: Urine leakage from both stress incontinence and urge incontinence. It is very common to have mixed incontinence as opposed to pure stress or urge incontinence.
Urinary incontinence can be diagnosed by using a variety of tests, including a urinalysis to check for abnormalities, post-void residual measurement to measure urine output and leftover urine in the bladder, or through the use of a bladder diary to track your frequency of urination.
Pelvic Organ Prolapse (POP)
Pelvic Organ Prolapse (POP) is a disorder in which women experience a protrusion (bulge) at or near the vaginal opening. The protrusion may be accompanied by perineal pressure (pressure between the vagina and anus).
There are other types of prolapses that can protrude into the vaginal canal as a result of weak pelvic floor muscles. These include:
- Cystocele: prolapse of the bladder
- Rectocele: prolapse of the rectum
- Urethrocele: prolapse of the urethra
- Uterine prolapse: prolapse of the uterus
- Vaginal vault prolapse: prolapse of the top of the vagina after a hysterectomy
- Enterocele: prolapse of the intestines
Women that have POP often experience difficulty initiating urine flow and may strain to have a bowel movement. In men, a pelvic organ prolapse will occur in the rectum. The individual will feel like he needs to have a bowel movement, but is unable to go.
Hypertonic Pelvic Floor Dysfunction
Hypertonic pelvic floor muscles are muscles that are too tight. Your pelvic floor muscles need to be able to contract in order to maintain continence, and relax to allow for urination and bowel movements. When these muscles are too tight and have too much tension (hypertonic), they may cause pelvic pain and discomfort. There are many conditions caused by hypertonic pelvic floor dysfunction which can greatly benefit by seeing a pelvic floor physiotherapist, including: dyspareunia, vaginismus, vulvodynia, pudendal neuralgia, and chronic prostatitis.
Dyspareunia is the medical term for pain associated with intercourse. Surgery or trauma can cause injury to the pelvic floor muscles, and conditions like dyspareunia can result from the painful, hypertonic muscles.
Individuals suffering from dyspareunia will often feel aching pain or burning during intercourse. The pelvic floor muscles will then need rehabilitation, which may include pelvic relaxation exercises instructed by a pelvic physiotherapist in addition to medication, and sometimes counselling.
Vaginismus is a condition where during intercourse, a medical exam, or the insertion of a tampon, the vaginal muscles will squeeze or spasm and cause discomfort and possibly pain. These hypertonic spasms can affect the pelvic floor muscles and create too much muscle activity in the pelvic region. Vaginismus occurs during penetration and usually goes away after withdrawal, although not always.
Some women develop vaginismus when estrogen levels drop off after menopause, or after a surgery or trauma. This condition has also been linked to psychological issues from past sexual abuse or trauma, both physical and emotional.
Vulvodynia is a chronic discomfort of either the vestibule, or “entrance” of the vagina, clitoris, or the superficial tissues of the vulva. There are many causes for vulvodynia including injury to the nerves surrounding the vulvar region, connective tissue tightness, or pelvic floor muscle hypertonicity (present in 80% of patients with vulvodynia).
The most common signs and symptoms of vulvodynia include burning, aching, and itching that can last anywhere from months to years. Pain and irritation can occur during physical exercises like walking or biking, while inserting a tampon, or even while sitting.
To help diagnose vulvodynia, your doctor may do a cotton swab test. By using a moist cotton swab to place pressure on various parts of the vulva, your doctor will be able to identify the location and intensity of your pain, to help determine the best course of action.
Pudendal Neuralgia is a condition that causes pain, discomfort, or numbness in the pelvis or genitals as a result of major nerve damage to the lower body and/or pudendal nerve. The pudendal nerve runs from the back of the genitals and branches off into other nerves. There are many ways that the pudendal nerve can get damaged, resulting in pelvic floor dysfunction; it can happen while birthing, from an infection, or during certain types of exercises, like biking.
The sharp pains or numbness resulting from damage to the pudendal nerve may intensify if you sit down, and may spread to the sides of your body, your belly button, legs, and buttocks. It can also result in the sudden and frequent urge to urinate.
To determine if your pelvic floor dysfunction is associated with pudendal neuralgia, your doctor may perform a physical exam by placing their finger on the pudendal nerve. They may also suggest an MRI test to better determine if damage has occurred, or recommend a pudendal nerve block to numb the nerve and see if this helps reduce symptoms.
Chronic Prostatitis is the inflammation of the prostate. It’s often painful and can affect sexual function and the ability to urinate. The prostate is a small gland that sits under the bladder and surrounds the urethra. This is the leading cause of urinary tract issues for men under the age of 50 and is the third most common urinary tract issue for men over the age of 50. Often, chronic prostatitis stems from issues with the pelvic floor muscles. When the pelvic floor muscles are too tight or strained, they can irritate the surrounding nerves and cause radiating pain.
What is Pelvic Physiotherapy?
Pelvic floor physiotherapy, also called pelvic therapy, is the assessment and treatment of various conditions involving the pelvic floor muscles and the surrounding areas. This group of muscles is important for bladder and bowel control, sexual function, healthy pregnancies, spine stability, and more. Pelvic therapy can help treat the various conditions that cause pain and discomfort in the pelvic area of the body.
Pelvic physiotherapists are specially trained to evaluate the bones and muscles of your lower back, your hips, your sacroiliac joint, as well as your pelvic floor muscles. These rehabilitative health care professionals develop individualised care plans for their clients, to provide treatment and exercise programs that help manage pain and discomfort in the pelvic region.
Pelvic physiotherapy may also be part of a treatment plan that involves your primary care physician, sex therapists, and mental health therapists.
Pelvic Physiotherapy Treatment & Exercises
Based on the assessment performed by your pelvic physiotherapist, he or she will put together care plan that is specific to your individual symptoms and pelvic floor condition. Pelvic physiotherapists use a number of exercises and treatments to meet your specific needs, including manual therapy, electrical muscle stimulation (EMS), biofeedback devices, hypopressive exercises, percutaneous tibial nerve stimulation (PTNS), bladder and/or bowel routine tracking, and more.
Manual therapy involves hands-on techniques to treat soft tissues – it is the gold standard when treating pelvic floor dysfunction. Techniques such as stretching, soft tissue massage, myofascial and trigger point release, and connective tissue manipulation are used to contract or release muscle tension and provide pain relief. In addition, your pelvic physiotherapist can help alleviate pain by using heating/cooling pads, and through breathing and relaxation techniques.
An individual may be given an individualized exercise program to stretch and strengthen pelvic muscles and improve posture. Men and women will often be given different exercises as women face different pelvic floor conditions than men.
Hypopressive exercises, for example, are a series of specific posture and breathing techniques that are helpful in preventing urinary incontinence and prolapse conditions. They also help with improving general posture and stimulate the entire pelvic floor area. Combining specific positions and breathing techniques, these exercises help contract the pelvic and abdominal muscles to strengthen the pelvic floor muscles.
Electrical Stimulation Devices
- Electrical Muscle Stimulation (EMS), also known as Neuromuscular Electrical Stimulation (NMES), is a treatment that uses electrical impulses to contract the pelvic floor muscles in order to improve their strength. EMS also helps with immediate relief of pelvic pain and the feelings of urgency.
- Percutaneous Tibial Nerve Stimulation (PTNS) is a low-risk, non-surgical treatment that works by providing indirect electrical stimulation to the nerves responsible for bladder and pelvic floor function. First, a slim needle electrode is placed near the nerve at the ankle (known as the tibial nerve). The electrical stimulation then travels to the sacral nerve plexus, a group of nerves at the base of the spine responsible for bladder function. This treatment has been found to be effective for those struggling with urinary and fecal incontinence.
- Biofeedback devices help retrain weak or poorly functioning pelvic floor muscles. An electrical or mechanical device is used to help provide auditory or visual feedback on how well or poorly you are using your pelvic floor muscles. This information helps the pelvic physiotherapist know what subtle changes in your body, such as relaxing certain muscles, is needed to achieve the desired results, like reducing pain.
- Trans-Electrical Nerve Stimulation (TENS) is a machine that stimulates your nerves (around your pelvic area) via an electric current through your skin. TENS can help assist you in short-term pain relief under the guidance of a pelvic physiotherapist.
- Interferential Current Therapy (IFC) is a type of therapy where the pelvic physiotherapist places electrodes on your skin around the pelvic area. The device transmits electrical impulses in small quantities through your skin in order to stimulate the tissues and nerves. This type of treatment is useful in reducing pain, inflammation, and intensity of muscle spasms.
Bladder Symptom Diary
A bladder symptom diary is used to keep track of every bladder and/or bowel movement. This information keeps your pelvic physiotherapist informed about your bladder and/or bowel movements so that they can take appropriate measures with your treatment.
Your pelvic physiotherapist doesn’t only provide treatment, but they help you understand your pelvic floor condition and the reasons for your symptoms. Understanding the anatomy and physiology of the pelvic floor, as well as how to deal with chronic pain symptoms is important for your recovery.
How to Find a Pelvic Physiotherapist
The first step to finding a pelvic physiotherapist should be to visit your doctor and have him or her assess your condition to decide on the best course of action. If pelvic physiotherapy is the right choice for you, your doctor can refer you to a pelvic physiotherapist, or you can find a pelvic physiotherapist on your own.
Pelvic Physiotherapy Costs
Although most physiotherapy services are covered under OHIP, pelvic physiotherapy does not fall under this category. This means that you’ll have to pay privately to receive pelvic physiotherapy. Thankfully, most extended health benefit plans and private insurance plans will cover part, if not all of the costs for your pelvic physiotherapy.
Private pelvic physiotherapy will cost approximately $125 for the initial assessment and between $75 and $90 for each follow up visit, depending on the length of the visit. These prices vary depending on the clinic and the qualifications of the pelvic physiotherapists, but represent the general costs of pelvic physiotherapy within Ontario.
Do You Need Pelvic Physiotherapy?
Pelvic floor dysfunction affects so many people, but most Canadians aren’t getting the proper medical attention due to shame and the fear of embarrassment. If you suffer from pelvic floor dysfunction, know that you are not alone. Conditions associated with pelvic floor dysfunction are both common, and treatable.
If you’re feeling any symptoms that you think might be caused by pelvic floor dysfunction, please visit your family doctor or speak with a pelvic physiotherapist directly. There’s no reason to feel embarrassed in seeking the appropriate medical care – pelvic physiotherapists aren’t here to make judgements, they simply want to help.